Medical Director of Policy Innovation
15 hours ago
We are seeking a highly skilled Medical Director of Medical Policy to join our team at Blue Shield of California. As a key member of our Medical Management team, you will play a critical role in ensuring that our medical, medication, and payment policies are at the forefront of innovation and excellence.
Key Responsibilities- Provide clinical oversight and input for Medical Policy operations, ensuring that our policies are evidence-based and effective.
- Chair the Medical Policy Committee, driving strategic decision-making and collaboration with stakeholders.
- Work closely with the Pharmacy Services team to promote safe, effective, and cost-efficient pharmaceutical care for our members.
- Provide medical expertise in daily clinical rounds for drug authorization case review, ensuring that our policies are implemented consistently and effectively.
- Collaborate with the Payment Policy Committee to oversee and advise on payment policies, claims editing code loads, and other clinical code editing issues.
- Provide subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, and provider DOFRs.
- Consult with Blue Shield of California legal to support fraud and abuse investigations, provider arbitrations, regulatory inquiries, and issues related to clinical policy, coding, or pricing.
- Act as Blue Shield's representative to the Blue Cross Blue Shield Association (BCBSA) Technology Assessment process and the Medical Policy Panel.
- Partner with Network Management and Provider Partnership staff to resolve issues with Blue Shield providers related to clinical policy, coding, and billing.
- A Medical degree and 12 years' experience, including a minimum of 5 years' experience in active clinical practice in an adult-based primary care specialty (internal Medicine or Family Practice).
- Unrestricted California State Medical License required.
- Active Board Certification in one of ABMS categories, preferably Internal Medicine, required.
- Prior health plan experience - specifically with medical and medication policy development, technology assessment, and clinical coding preferred.
- Clinical work in a primary care discipline (Internal Medicine, Family Practice, Pediatrics) or General Surgery desired.
- Understanding of the California marketplace, including California health care laws and regulations desired.
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Medical Director, Medical Policy and Innovation
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Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryBlue Shield of California is seeking a highly skilled Medical Director, Medical Policy and Innovation to lead our medical policy and payment initiatives. As a key member of our Medical Management team, you will be responsible for providing clinical oversight and input for medical policy operations, chairing the Medical Policy Committee, and...
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Medical Director of Policy Innovation
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Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Medical Director of Medical Policy will play a critical role in shaping the medical management strategy at Blue Shield of California. As a key member of the Medical Management team, you will be responsible for providing clinical oversight and input for medical policy operations, including chairing the Medical Policy Committee.In this role, you...
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Medical Director, Medical Policy and Innovation
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Medical Director, Medical Policy
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Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryThe Medical Director, Operations - CalPERS will play a critical role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management.Key ResponsibilitiesClinical Review and Management: Deliver and...
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